Door-to-unload: left ventricular unloading before reperfusion in ST-elevation myocardial infarction

ST-elevation myocardial infarction treatment in the modern era has focused on minimizing time of ischemia by reducing door-to-balloon time to limit infarct size and improve survival. Although there have been significant improvements in minimizing time to coronary reperfusion, the incidence of heart failure following a myocardial infarction has remained high. Preclinical studies have shown that unloading the left ventricle for 30 min prior to coronary reperfusion can reduce infarct size and promote myocardial recovery. The DTU-STEMI randomized prospective trial will test the hypothesis that left ventricular unloading for at least 30 min prior to coronary reperfusion will improve infarct size and heart failure-related events as compared with the current standard of care.

Abstract 263: The Relationship Between Time to Extracorporeal Cardiopulmonary Resuscitation and Coronary Reperfusion and Short-term Outcome in Out-of-hospital Cardiac Arrest Patients Due to Acute Coronary Syndrome

Background: In out-of-hospital cardiac arrest (OHCA) patients due to acute coronary syndrome (ACS), the association between time to extracorporeal cardiopulmonary resuscitation (ECPR) or coronary reperfusion and clinical outcome has yet to be well-known. Methods: Between June 2014 and 2017, we enrolled a total of 34,754 OHCA patients in multicenter, prospective fashion (JAAM-OHCA registry). Following exclusion criteria, 254 OHCA patients with underwent ECPR and emergent PCI were eligible for this study (59±12 years-old; 92% male). We investigated the association between call-to-ECPR or call-to-reperfusion and the survival at 30 days. Results: The survival patients were 85 (33%). Figure shows the numbers of patients according to call-to-ECPR interval. The call-to-ECPR interval and call-to-reperfusion interval in survival patients were significantly shorter than those in non-survival patients (51±16 vs 61±16 min, p<0.01; 123±50 vs 157±133 min, p=0.03, respectively). Receiver operating curve analysis indicated call-to-ECPR interval cutoff point of 46 min (area under the curve 0.70, sensitivity 48%, specificity 84%) and call-to-reperfusion interval cutoff point of 92 min (0.61, 37% and 81%, respectively) for predicting survival at 30 days. Multivariate logistic regression analysis revealed call-to-ECPR interval and call-to-reperfusion as the independent predictors of survival (OR 0.96, 95%CI 0.94-0.98, p<0.01; OR 1.00, 95%CI 0.99-1.00, p=0.03, respectively). Conclusion: The call-to-ECPR interval and call-to-reperfusion interval are independent predictors of survival at 30 days in OHCA patients due to ACS.

Implication of anti-angiogenic VEGF-A165b in angiogenesis and systolic function after reperfused myocardial infarction

Background Angiogenesis participates in re-establishing microcirculation after myocardial infarction (MI). Purpose In this study, we aim to further understand the role of the anti-angiogenic isoform vascular endothelial growth factor (VEGF)-A165b after MI and explore its potential as a co-adjuvant therapy to coronary reperfusion. Methods Two mice MI models were formed: 1) permanent coronary ligation (non-reperfused MI), 2) transient 45-min coronary occlusion followed by reperfusion (reperfused MI); in both models, animals underwent echocardiography before euthanasia at day 21 after MI induction. Serum and myocardial VEGF-A165b levels were determined. In both experimental MI models, functional and structural implication of VEGF-A165b blockade was assessed. In a cohort of 104 ST-segment elevation MI patients, circulating VEGF-A165b levels were correlated with cardiovascular magnetic resonance-derived left ventricular ejection fraction at 6-months and with the occurrence of adverse events (death, heart failure and/or re-infarction). Results In both models, circulating and myocardial VEGF-A165b presence was increased 21 days after MI induction. Serum VEGF-A165b levels inversely correlated with systolic function evaluated by echocardiography. VEGF-A165b blockage increased capillary density, reduced infarct size, and enhanced left ventricular function in reperfused, but not in non-reperfused MI experiments. In patients, higher VEGF-A165b levels correlated with depressed ejection fraction and worse outcomes. Conclusions In experimental and clinical studies, higher serum VEGF-A165b levels associates with a worse systolic function. Its blockage enhances neoangiogenesis, reduces infarct size, and increases ejection fraction in reperfused, but not in non-reperfused MI experiments. Therefore, VEGF-A165b neutralization represents a potential co-adjuvant therapy to coronary reperfusion. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was funded by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” (Exp. PIE15/00013, PI17/01836, PI18/00209 and CIBERCV16/11/00486).

Predictive factors for myocardial infarction in pre-hospital emergency care

Background: Identifying predictive factors based on procedures carried out by emergency medical teams may speed up the diagnosis of AMI. By shortening the time between the onset of the pain and the initiation of coronary reperfusion, patient prognosis can be improved Methods: The study was conducted on residents of the Bielsko-Biała district, served by state ambulance service Medical Response Teams (MRT). The patients were assigned to the following groups: Group A (n = 338) - patients with chest pain in whom infarction with elevation of the ST segment (ST-ACS) was diagnosed on the basis of an ECG, Group B (n=300) - patients with chest pain in whom an infarction was not diagnosed. A factor structural test for the studied parameters was used to determine their significance. An odds ratio (OR) was established for statistically significant parameters, and multi-dimensional logistic regression analysis was conducted. The significance of the odds ratios (OR) was estimated for individual risk factors based on 95% confidence intervals (CI). Results: It can be stated with 95% probability that the significant parameters: Male (p=0.00001), Age 51-70(p=0.00307), Breathing rate less than 12/min(p=0.02711), Pulse below 60 min (p=0.00165), Edemas (p=0.00075), Moist skin(p<0.01), Sinus rhythm (p=0.00004), Additional ventricular beats(p=0.00133) increase the risk of myocardial infraction. Conclusion: Identifying the predictors of myocardial infarction specific to pre-hospital emergency care is essential for improving the detection of AMI and shortening the time between calls to the MRT and the initiation of coronary reperfusion.